Provider Demographics
NPI:1932535846
Name:LAUTERBACH, ELIZABETH MAURENE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MAURENE
Last Name:LAUTERBACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MAURENE
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1200 E PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-6141
Mailing Address - Country:US
Mailing Address - Phone:580-379-5000
Mailing Address - Fax:580-379-5509
Practice Address - Street 1:205 S PARK LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5755
Practice Address - Country:US
Practice Address - Phone:580-379-6650
Practice Address - Fax:580-379-6659
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200511530AMedicaid